Dental Tribune Middle East & Africa Edition No.2, 2016

Dental Tribune Middle East & Africa Edition | 2/2016 17 restorative Anidealcombinationfor optimizedestheticsuccess CAD/CAMtechnologyprovidesanefficientandreliablemethodtocreatefull-contourrestora- tionsfrom high-qualityzirconiaforcomplexrestorativeneedsintheposteriorregion. By Marko Jakovac, DMD, MSc, PhD, Croatia, and Michele Temperani, CDT,Italy Modern dentistry is not only con- cerned with oral hygiene or caries prevalence – wear from attrition, abrasion or erosion is increasingly becomingasubjectofconcern. These destructive oral processes are in large measure attributable to stress. Stress can trigger parafunc- tional habits and lead to gastric re- fluxandlowpHvaluesinsaliva. Additionalfactorssuchasbulim- iaandexcessiveconsumptionofsoft drinksalsocomeintoplay. Casepresentation A 30-year-old female patient pre- sented at our practice with pain in the posterior region. She was also dissatisfied with the esthetic ap- pearance of her anterior teeth (Fig. 1). Considerable erosive loss of tooth structure on the palatal and cervical surfaceswasobservedattheprelimi- nary examination (Fig. 2). An initial interview revealed that the patient consumed large quantities of soft drinks. On the basis of the clini- cal findings, we concluded that the woman was suffering from stomach problemswithsuspectedbulimia. Treatment planning After careful history taking and a thorough assessment including a radiographic evaluation, we began to develop a treatment plan. The plan was to rehabilitate the entire oral cavity, to restore all teeth that had been damaged by erosion or tooth decay and to protect the exist- ing dentition from further damage. We aimed at restoring the shape and function of the teeth by raising the vertical dimension of occlusion. Interventions involving such a high level of complexity require both a comprehensive plan outlining in de- tail every part of the treatment and close collaboration between dentist and dental technician. Following initial examination, an impression and bite record were taken. Portray imagery and DSD technology (Digi- tal Smile Design) have proven to be highly useful in situations where the dental technician cannot gain an impression of the patient’s oral situ- ationinperson. Mock-upandinitial temporaries As provided for in the treatment plan, the dental technician fabri- cated a diagnostic wax-up to visual- ize the ideal oral situation. Wax-ups are convenient to assess the feasibil- ity of such complex prosthetic treat- ments. Duplicate casts were made from the contoured wax-up and sili- conematriceswerecreated(Fig.3).In the first step, the matrices assisted in the construction of the mock-up and, further on, in the fabrication of the baseline temporaries in the patient’s oral cavity. The mock-up was completed on the basis of the wax-up. It was then used to simu- late the final outcome on the patient and visualize the inclination of the occlusal plane (Fig. 4). The patient agreed to the treatment plan and we proceeded to implement the neces- sary surgical measures – i.e. tooth extraction and crown lengthening. It is important to consider the form identified in the wax-up when per- forming surgical crown lengthening (Fig.5).Subsequently,thepatientun- derwent periodontal treatment and root canal therapy. Additionally, all existingrestorationswerereplaced. Preparationandtemporization The teeth were prepared in two ses- sions. At the first session, we pre- pared the teeth along the gingival margin. Impressions were taken and temporaries fabricated. Generally, temporization is essential to achieve an optimum healing result after sur- gical crown lengthening and tooth extraction. Since the temporaries Fig. 1: Patient before the treatment: She wanted her esthetic appearance tobeimproved. ÿPage18 Fig. 2: On examination, a substantial loss of tooth struc- turein thecervicalandpalatalregionwasobserved. Fig. 3: Mock-up and temporaries were created using a siliconematrixof thewax-up. Fig.4:Mock-upplacedin thepatient’smouth Fig.5:Situationaftersurgicalcrownlengthening should follow the parameters estab- lished in the wax-up, we decided to employ CAD/CAM technology for thisstep. The wax-up and master models were digitized using a lab scanner (Wieland Dental) and the resulting data sets superimposed using dental design software (3Shape). This meth- od allowed us to transfer the shape of the wax-up to the model that contained the tooth preparations. The virtual project is automatically converted into a STL data format and sent electronically to the pro- gram responsible for the CAM pro- cess. In this case, the STL data were imported into the milling program of a Zenotec® mini CAD/CAM unit (Wieland Dental) to manufacture temporariesfromTelio®CADPMMA material (Fig. 6). Occlusal and func- tional adjustments were repeatedly performed over the three-month healing period (Fig. 7). After success- ful healing, the second stage of the preparationprocesswasimplement- ed. When carrying out this step, vis- ual aids (loupes, dental microscope) are recommended to achieve accu- rate results. After completion of the preparation procedure, an impres- sion of the oral situation was taken (Fig.8). Jaw relations were established withthehelpofabiterecord. The jaw position was “test driv- en” during the healing phase when the patient was wearing the tem- poraries. A special procedure (cross- mounting method) enables the clinician to communicate the jaw relations to the technician without lossofinformation. Procedure Before After Cleanic: Clinical use of a recognised prophy paste with Perlite By Dr. Fabio Cosimi D.D.S., Dr. Su- sanna Giovannini D.I., I-Ostia Lido, Rome Cleanic® prophy paste by Kerr has a creamy and smooth consistency. It also has a pleasant fresh taste that is not too strong and is well accepted bythepatient. This creaminess and the clever useofbindingagentshavemadethe paste easy to use. Available in a tube, used with both cups and brushes, the paste stays more compact on the tooth surface, thereby avoiding the unpleasant sensation caused by coarse particles left in the patient’s mouth. Within a few seconds after application (during the cleaning cy- cle),Cleanic®pasteremovesextrinsic dischromia caused by chlorexidine orstainscausedbycigarettesmoke. (If either of these are present in a patient at a recall of 6 months, the applicationshouldberepeated). About 8 seconds after applica- tion, the paste automatically starts its polishing action thanks to Perlite technologymakingthetoothappear smoothandshiny. After our usual professional oral hygiene procedures (debridement, scaling and root-planing), Cleanic® paste, compared with others on the market, seems to be less apparent in thegingivalsulcus. Pro-BrushTM new generation brushesareverysuitableforpatients with dental overcrowding or malpo- sitioned teeth. Plastic replaces the traditional metal part and allows the brush to rotate more efficiently. This helps to prevent damage to adjacent teeth. Pro-Cup® cups have been de- signed and developed to avoid pastes being splattered as with tradi- tionalcups. Michele Temperani, CDT, Italy is a speaker at Dental Technician Int'l Meeting! 06-07 May 2016 | Jumeirah Beach Hotel, Dubai, UAE Dental Tribune Middle East & Africa Edition | 2/201617